Journal ID (publisher-id): jgi
Publisher: Centre for Addiction and Mental Health
Article Categories: review
Publication issue: Volume 49
Publication date: January 2022
Publisher Id: jgi.2022.49.1
|Tomonari Irie||School of Education and Culture, Hokusho University, Hokkaido, Japan|
|Yokomitsu Kengo||Faculty of Health and Welfare, Kawasaki University of Medical Welfare, Okayama, Japan|
It has been determined that family members and relationship partners of persons with gambling disorders face a variety of problems. Since their problems have not yet been summarized in the literature, we conducted a scoping review to address this issue, and focused on the studies of problems faced by family members and partners of those with gambling disorders and studies on the effects of gambling problems on family members and partners. We searched electronic databases (PsycINFO, PubMed, and MEDLINE) and the reference lists of included studies published up to February 15, 2021 and extracted 2,760 studies. These studies were examined for eligibility, and yielded 101 items that met our predefined criteria, all of which were reviewed. Overall, this review found that (1) the presence of gamblers in families was related to increased gambling or other addiction-related behaviors among family members; (2) a variety of intra-family conflicts were likely to arise between gamblers and their families and partners; (3) the presence of gamblers in families increased the risk of violence and abuse for family members, partners, and gamblers themselves; and (4) gambling problems generated a variety of physical and mental health problems in gamblers’ families as well as among others in their proximity. In the future, it will be important to establish beneficial support and treatment methods by using the difficulties identified by this review as outcomes in the treatment of gamblers, along with their families and partners.
Keywords: problem gambling, relationship partners, family, literature review
The lifetime prevalence of gambling disorders in people who speak English and other European languages has been reported as 0.8–1.2% (Stucki & Rihs-Middel, 2007). Among college and university students, 10.2% have probable gambling disorder (Nowak & Aloe, 2014). Moreover, certain treatment-seeking disordered gamblers display current and lifetime co-morbid Axis I disorders (nicotine dependence, major depressive disorder, alcohol abuse and dependence, and so on; Dowling et al., 2015). Sato (2008) reported that many patients with gambling disorders received no medical care or psychological support. Moreover, their families and relationship partners must confront gambling-related difficulties such as financial, legal, and occupational challenges.
The difficulties faced by families and partners because of gambling behavior are a worldwide problem. For example, Darbyshire et al. (2001) reported that growing up in a family where parents have serious gambling problems could worsen children’s overall health and well-being. Moreover, Kourgiantakis et al. (2013) conducted a review of empirical studies published from 1998 to 2013 examining the effects of gambling disorders on families and the impact of family involvement in gambling treatment. This review showed that gambling disorders had several adverse effects on families. Meanwhile, family involvement in treatment of gambling disorders was linked with better treatment outcomes and improved individual and family functioning. In fact, family members’ and partners’ motivation and assertiveness towards disordered gamblers appear to be important factors for gamblers’ treatment entry. As such, community reinforcement and family training could target the acquisition and development of skills by family members and partners (Archer et al., 2020). Family members’ and partners’ involvement in treatment could certainly improve treatment outcomes. However, given the variety of difficulties family members and partners face, providing them with significant care and support is also crucial. Therefore, updating the findings on difficulties faced by families is important in understanding those families and partners who may be victims of gambling disorders.
The purpose of this scoping review is to consolidate previous findings and identify the impact of gambling disorders on families and partners, to promote the understanding of the relationship between people with gambling disorders and their families and partners. Specifically, we reviewed and summarized the research that has reported on the difficulties faced by family members around people with gambling disorders. In addition, based on the results of this review, we shall discuss ways to support gamblers, their families and partners, as well as the interpersonal relationships between them. Difficulties were faced not only by individual family members or partners (e.g., health problems or behavior) but also included issues that arose between family members and people with gambling disorders (e.g., conflicts and violence). In addition, certain of these issues were reported from the perspectives of family members or partners, while others were from the perspectives of gamblers. All the issues were identified through questionnaire surveys, or by interviewing both parties separately. Therefore, we defined these as difficulties faced by the families or partners.
In this study, “family members” includes parents, children, siblings, grandparents and other relatives, while “relationship partners” includes both close personal friends and persons with whom the subject in question is in a relationship. Furthermore, previous studies’ concept of “pathological gambling” was defined as a gambling disorder in this scoping review because the term pathological gambling is not used in the latest diagnostic criteria (American Psychiatric Association, 2013).
This scoping review searched the following databases (PsycINFO, PubMed, and MEDLINE). The selected search terms were “gambling” and “family, child, adolescent, or significant others.” The search included articles published from the earliest data available to February 15, 2021 in each database. Moreover, after these database searches, we also searched the reference sections of the articles for additional sources. The first and second authors independently screened the title and abstract to identify and exclude those that were irrelevant. The first and second authors then independently screened the full text of all remaining articles for relevance. Any discrepancies were discussed and resolved by two authors. Studies included for this review met the following criteria: (1) written in English, (2) published in a peer-reviewed journal, and (3) conducted specifically with families or partners who faced gambling related difficulties or examined the impact of gambler’s behaviors and problems on families or partners.
For each study that met the inclusion criteria, the first author extracted data on general study details, participant’s characteristics, and the results in relation to the impact of gambler’s behaviors and problems on families and partners. And then, second authors checked the data the first author had extracted.
Based on the inclusion criteria, two independent raters evaluated “include,” “excluded,” and “unsure” for each article. The value of Kappa indicates fair agreement (κ = .50) (Higgins & Green, 2008). Of the 2,760 articles extracted using the database search, we rejected 2,360 articles for which both the raters evaluated “exclude.” This process resulted in 400 articles, of which 25 articles received the same “include” evaluation by both raters, 113 articles received the same “unsure” evaluation by both raters, and 262 articles were evaluated as either “include” or “unsure” by either rater. There were 86 duplicates among the 400 articles. Moreover, as a result of the reference section search, we further extracted 28 articles. Finally, two raters independently read the full texts of the 342 articles and judged whether they should be subject to this review. A total of 101 articles were selected for this review (Figure 1). We further categorized the gambling related difficulties faced by families or partners into (a) gambling behaviors, other addictive behaviors, and related problems; (b) conflicts with gamblers; (c) violence and abuse inflicted upon and perpetrated by them; and (d) physical and mental health problems, based on the information obtained from the extracted papers. Duplicates were counted when multiple reports of impact were included. Incidentally, because almost all families and partners were facing financial problems related to debt or bankruptcy (Grant et al., 2010), we excluded financial problems in this review and focused on other difficulties. In addition, the results and discussion were based on the PRISMA-ScR checklist (Tricco et al., 2018).
The majority of studies focusing on how gamblers’ behaviors and related problems could result in families’ and partners’ gambling behaviors, other addictive behaviors, and related problems were extracted through previous studies. We reviewed two review articles (Kalischuk et al., 2006; Walters, 2001) and 44 observational studies. The details of these studies are presented in Table 1. Forty-one studies examined the impact of gambling behaviors and problems on families’ or partners’ gambling behaviors and gambling-related problems and five studies examined the impact of gambling behaviors and problems on families’ or partners’ substance abuse behaviors and related problems.
The two review studies (one literature review, one meta-analysis review) indicated that the disordered gambler is more likely to have a parent who has experienced gambling disorder (Kalischuk et al., 2006). The results of the meta-analysis in relation to examining familial effect on disordered gambling showed a small but significant overall effect size (weighted φ = .10; 95% confidence interval = .08 to .12) (Walters, 2001). These results indicate that having a family member who gambled or was a disordered gambler could be a factor resulting in other family members’ gambling or disordered gambling (Apinuntavech et al., 2012; Barry et al., 2009; Browne & Brown, 1994; Dowling et al., 2017; Dowling et al., 2020; Oei & Raylu, 2004; Shirk et al., 2018). Therefore, much evidence has emerged in existing studies that family dynamics can influence the development of gambling disorders.
Regarding these dynamics, earlier research indicated that most children of parents who had gambled or been classified as disordered gamblers also gambled (Boldero & Bell, 2012; Sheela et al., 2016; Vachon et al., 2004; Vitaro & Wanner, 2011). In particular, Lesieur and Rothschild (1989) reported that 80% of 105 children of Gamblers Anonymous members have gambled. Moreover, some research has indicated that children gambled with their family members and that children’s gambling was caused by forced involvement in parental gambling. Through interviews, Reith and Dobbie (2011) reported that, regarding first gambling participation, a respondent had said, “when my father asked me to buy lotteries on lottery house, I bought father’s lotteries and my own lotteries out of interest.” McCarthy et al. (2020) reported that parents either gave their children money for gambling, took them to gambling venues, or held their eighteenth birthday party in a gambling venue. Moreover, Gupta and Derevensky (1997) found that 20% of children were fearful of being caught by other family members helping their parent’s gambling. Furthermore, Dickson et al. (2008) conducted a survey of 2,179 students (aged 11–19 years) from 32 schools in Ontario, Canada, to determine whether their parents had gambling problems. The results showed that the group of children with the most-severe gambling problems had a higher percentage of parents with gambling-related problems, but even in the group of children with lower levels of gambling problems, a certain number of parents were found to maintain gambling-related problems. Dowling et al. (2016) conducted a telephone survey of 3,953 Australian residents (aged 18–70 years) about the presence of gambling-related problems in their parents. Results revealed that gambling-related problems in parents were more prevalent in the more severe gambling group, but gambling-related problems were also found in parents among those who did not gamble. As mentioned above, earlier research has indicated that gamblers’ behaviors affect the gambling behaviors of their family members, especially adolescents or children, but the severity, with which it affects them is still not known.
For other substance abuse-related addictive behavior and problems, Jacobs et al. (1989) reported that 52 of 844 high-school students had one or both parents who were problem gamblers; these children had a higher prevalence of gambling behaviors (8% vs. 4%), smoking behaviors (37% vs. 23%), and cocaine use (10% vs. 5%) than children whose parents did not have these problems. Regarding smoking behaviors, Schreiber et al. (2009) observed a similar tendency (children whose parents had problem gambling vs. children whose parents did not: 51.7% vs. 35.7%). Tulloch et al. (2020) found that people whose family members had gambling problems were at a significantly higher risk of experiencing alcohol or drug problems than those without gambling problems.
In summary, earlier studies indicated that the presence of gamblers in families is related to increased gambling or other addiction-related behaviors among family members.
In this domain, we reviewed two review articles (Kalischuk et al., 2006; McComb et al., 2009) and 34 observational studies. The details of these studies’ results are summarized in Table 2. Fifteen studies examined worsening relationships, including sexual relations, between gamblers and family members or partners, 11 studies examined arguments with family members or partners, 5 studies declining communication, and 3 studies gamblers’ lying and hiding behaviors.
Kalischuk et al. (2006) indicated that family conflicts, such as arguments and poor communication with gamblers, could have the most serious impacts on their family members. McComb et al. (2009) conducted a literature and clinicians’ experience review on the effects of disordered gambling on families and partners. The results showed that gamblers are in danger of losing their partner’s trust, have impairment in roles and responsibilities, lack satisfaction in sexual relationships, face the possibility of separation or divorce, and have low quality marital relationships.
Many studies reported that people with gambling disorders had worse relationships with their families and partners (e.g., Bergh & Kühlhorn, 1994; Carr et al., 2018; Dowling et al., 2009; Lorenz & Shuttlesworth, 1983; Pietrzak & Petry, 2006). For example, Crisp et al. (2001) conducted an interview survey of 440 family members and partners around gamblers who used a counselling service for gambling problems in Victoria, Australia, between 1997 and 1998. The results showed that 71.3% of men and 75.9% of women reported having interpersonal problems with gamblers. Thus, the problems associated with gambling give rise to conflicts with gamblers’ families and those around them. Dickson-Swift et al. (2005) conducted interviews with seven family members and partners living in Australia and summarized their relationships with gamblers. All of the participants’ relationships with gamblers were deteriorating. Three had severed the relationship through divorce or breakup, and one participant was frustrated but unable to break up the relationship. All four of those who had an ongoing relationship reported that they did not trust the gambler.
In a survey of gamblers, the percentage experiencing arguments with family members and partners ranged from 0.07% to 61.3% (Abbott & Cramer, 1993; Downs & Woolrych, 2010; Gerdner & Svensson, 2003; Goldstein et al., 2013; Kumagami, 2014), but the percentage was as high as 77.3% among those who scored 5 or more on the South Oaks Gambling Screen (SOGS; Lesieur & Blume, 1987), a measure of the severity of gambling disorders (Dickerson et al., 1996). In other words, the severity of the gambling problem is a contributing factor to increased arguments between gamblers and their families/partners. Furthermore, in the survey of 96 outpatients at a clinic in Connecticut, USA, conducted by Pietrzak et al. (2005) between 2000 and 2002, 14.6% of people with gambling disorders reported having serious conflicts with family members in the past month. Earlier studies also indicated that decreased communication with gamblers is another form of intra-family conflict. In an interview study conducted in clinics or self-help groups between 2005 and 2010 by Black et al. (2012), 51% of 95 pathological gamblers reported that they did not communicate with their families. In addition, Dowling et al. (2014) conducted a questionnaire survey of 212 individuals facing gambling problems: 25.4% of respondents had not communicated with their families at all in the past three months.
Furthermore, gamblers lying to or deceiving family members is a frequent gambling symptom, as stated in the diagnostic criteria for gambling disorder, and at the same time is a problem faced by family members and partners around them. Martinotti et al. (2006) conducted a questionnaire survey of 27 pathological gamblers (SOGS score of 5 or more) and 38 individuals who were non-problem gamblers (SOGS score of 0) and calculated the coefficient of association of the SOGS items. The results showed that hiding signs of gambling (mean square agreement coefficient = .73) and lying about gambling (mean square agreement coefficient = .54) were items that were more strongly differentiated between the two groups.
As mentioned above, the present review suggests that a variety of inter-family conflicts are likely to arise between gamblers and their families and partners, although this relationship has not been demonstrated using large-scale data.
In this domain, we reviewed two review articles (Dowling et al., 2014; Lane et al., 2016) and 24 observational studies. The details of these studies’ results are summarized in Table 3. Violence and abuse related to family members or partners, especially intimate partners, were mainly analyzed as victimization of them and perpetration by them. Infliction of violence and abuse on them mainly included physical (e.g., Afifi et al., 2010; Bland et al., 1993; Carr et al., 2018; Echeburúa et al., 2013; Lee, 2014; Lesieur & Rothschild, 1989; Lorenz & Shuttlesworth, 1983; Carr et al., 2018; Mullean et al., 2002) and sexual violence (Brasfield et al., 2012; Izmirli et al., 2014; Korman et al., 2008), but in the worst case it also included murder (Anderson et al., 2011).
Dowling et al. (2014) conducted a systematic review of the relationship between gambling disorder and family violence. They reviewed 14 articles and showed that 38.5% of family members or partners were victims of family violence, while 38.1% were also perpetrators. Thus, family members or partners may be either victims or perpetrators of violence (Dowling et al., 2018; Lavis et al., 2015; Roberts et al., 2018). In addition, Lane et al. (2016) indicated a positive relationship between disordered gambling, child physical abuse, and maltreatment through a systematic review of 12 studies. Current gambling problems could be associated with increased risk of child abuse.
In addition, Dowling et al. (2014) suggested that the probability of family violence could increase when the gambler is unemployed, or when the gambler or family members or partners have anger inhibition problems. Moreover, Korman et al. (2008) conducted a study on family violence among 248 problem gamblers aged 18 years and older: 53.7% of male and 65.1% of female gamblers reported committing family violence. In addition, gender differences on kinship violence were also examined, with a higher percentage of women reported to have caused injury to their partner than men (48.8% and 22.0%, respectively). The relationship between the severity of gambling symptoms and family violence was examined by Schluter et al. (2008) using data from a cohort study collected between March and December 2000 in Auckland, New Zealand. The results indicated that there was no statistically significant positive correlation between gambling symptoms and the number of incidents of family violence. On the other hand, Liao (2008) conducted a survey of 31 Chinese community members (family members and others around them) in the state of San Francisco and the surrounding Bay Area in the United States. The results showed that gamblers with a SOGS score of 10 or more had a 27.5 times higher risk of incidents of intimate violence compared to those with a score of 9 or less. Thus, it is currently impossible to conclude that the more severe the gambling, the more incidents of family violence occur, but it is possible that the risk of its occurrence may increase beyond a certain level of severity (Dowling et al., 2018). Furthermore, Anderson et al. (2011) described the case of a gambler killing his family in Estonia. The gambler was a 33-year-old man with a wife and two children. He was an avid sportsman in his school days and had performed well after joining the army. He began gambling in 2002, racked up debt from his parents and friends, and was so mentally and physically exhausted that he was diagnosed with major depressive disorder in 2005. Finally, in 2007, he murdered his entire family and committed suicide. The paper was based on police survey data and included several eyewitness accounts, psychiatric attendance records, and interviews with acquaintances, work colleagues, and clinical psychologists.
In summary, earlier studies indicated that the presence of gamblers in families increased the risk of violence and abuse for family members or partners. However, we found that family members were not only victims, but also became perpetrators and committed violence against the gamblers in their families. In any case, problem gambling holds the potential to cause physical harm to someone in the family.
In this domain, we reviewed one review article (McComb et al., 2009) and 19 observational studies. The details of these studies’ results are summarized in Table 4. Nine studies examined the physical health of gamblers and other family members or partners (e.g., Crisp et al., 2001; Lorenz & Yaffee, 1988, 1989) and 15 studies examined their mental health (e.g., Kalischuk, 2010; Lee, 2014; Lesieur & Rothschild, 1989; Mathews & Volberg, 2013; Suomi et al., 2014; Svensson et al., 2013; Tulloch et al., 2020; Vitaro et al., 2008).
McComb et al. (2009) reviewed clinicians’ experiences and literature on the impact of disordered gambling on marital and family relationships. The results showed that most people reported physical health problems including chronic and severe headaches, breathing difficulties, backaches, and stomach problems. Additionally, they found that spousal mental health issues included feelings of depression, anxiety, anger, isolation, and suicide. In the observational studies we reviewed, physical health problems were found in 77.3% (Dowling et al., 2014) and mental health problems were found in 50.0–97.5% of family members and those around them (Dowling et al., 2014; Lorenz & Shuttlesworth, 1983; Mathews & Volberg, 2013; Suomi et al., 2014). Thus, earlier studies have reported that gambling problems enjoy a considerably wide range of effects on the physical and mental health of family members and partners.
Lorenz and Yaffee (1988) conducted a survey of 215 spouses participating in three U.S. self-help groups (in Chicago, New York, and Pittsburgh) between 1983 and 1984 to examine in detail the physical and psychological symptoms their spouses were experiencing. The results revealed that the most common physical symptoms were headaches and stomachaches, and the most common mental symptoms were irritability, depression, and loneliness. In addition, Wong et al. (2014) conducted a study of the suicidal ideation of 3,686 gamblers and their families who used four gambling treatment centers in Hong Kong between 2003 and 2012: 720 (20.0%) gamblers with suicidal thoughts reported suicidal ideation, and 22 (0.6%) family members also reported familicidal-suicidal ideation because of gambling-related problems.
To summarize, these previous studies suggest that gambling problems could generate a variety of physical and mental health problems in gamblers’ families as well as among others in their proximity.
This scoping review inclusively examines difficulties among families or partners. This review also aims to assess the relationships between current gambling problems and difficulties faced by family members or partners. After a comprehensive review of their difficulties, we found that family members and partners faced diverse difficulties and problems. This review found that the effects of gambling disorders on family members and partners included the promotion of gambling and other addictive behaviors and their associated problems, conflicts, family violence, and physical or mental health problems (Figure 2).
Here, based on the results of this review, we have discussed directions for supporting gamblers, their families, and partners, as well as the interpersonal relationships between them from the clinical psychological perspective.
First, it was found that the presence of gamblers in families was related to increased gambling or other addictive behaviors among their family members. This finding can be explained through social networks, in which the presence of gamblers in the community influences the initiation of gambling (Reith & Dobbie, 2011). Therefore, irrespective of who the client is—a gambler, a family member, or a relationship partner—it is necessary to assess whether they have addictive behaviors that could develop into secondary gambling problems, and if necessary, treat them. Although abundant evidence exists on the intergenerational transmission of disordered gambling in the earlier studies, this review nevertheless suggested that the presence of gamblers in families could lead to increased gambling or other addiction-related behaviors among family members. However, we thought that the relationship between parents’ and children’s gambling/addictive behaviors may be explained by considering the mediating variables. It has been shown that abusive experiences can lead to future gambling in children via mental illness among children whose parents have gambling problems (Lane et al., 2016). This review also found that the presence of gamblers in families was associated with the risk of violence and abuse towards family members or partners. Therefore, in clinical situations, especially when children are engaged in addictive behaviors, it is necessary to check for instances of domestic violence against them. The intergenerational transmission of addictive behaviors should be discussed carefully because at this stage, it is still in the realm of speculation. There are no longitudinal cohort studies in this area. To clarify this mechanism, clinical research that identifies the intergenerational transmission is necessary in the future. However, regardless of the occurrence of addictive behaviors, given that many families and partners would be facing violence and abuse, such assessments are also important for improving their prognosis.
Furthermore, we found that family members became perpetrators of violence against the gamblers. Therefore, when supporting gamblers and their families, it is necessary to consider not only the possibility of gamblers committing violence against their family members, but also of family members perpetrating violence against the gamblers. While counselling gamblers it is important to assess whether they have been subjected to violence or abuse by family members or partners, and if necessary, to protect their safety through public institutions. Perpetration of violence by family members could be a way of relieving family stress rather than a solution to the gambling problem. Therefore, a thorough assessment of the relationships between the family members and the gambler, as well as family counselling, can help in building insight and minimizing instances of violence against the gambler.
Finally, this review extracted studies in which families or partners faced mental and health problems. Our findings suggest that we should not only work to reduce future gambling problems by providing support to the gambling person through treatment, but also assess and support the challenges of mental health problems and conflicts among family members. Furthermore, this review indicated a deteriorating relationship between children and partners. In mental health treatment, the development of positive relationships with family members is more likely to support recovery (Tew et al., 2012). However, as indicated in this review, gamblers may not be trusted, loved, and cared for by their families or partners, and may not have adequate support because of their lies, aggressive language, and violent interactions. In the worst case, the gambler will end up being left or divorced.
Gamblers have a wide variety of inappropriate behaviors towards their families or partners, which leads them to face problems in various aspects. Therefore, it is important to carefully listen to gamblers’ relationship with their families or partners and support them in acquiring appropriate behaviors. Specifically, it is necessary to change the behavior of lying into telling the truth and that of avoiding relations with family members or partners into committing to their relations. Improving the quality of family or significant other’s relationships is also what families or partners seek in the treatment of gamblers (Rodda et al., 2020). Community Reinforcement and Family Training, abbreviated as CRAFT, is one such systematic treatment system that has been established (Archer et al., 2020) and is used with gambling disorders (Nayoski & Hodgins, 2016).
There were certain limitations to this literature review. First, this study was a descriptive review. There were few meta-analyses in the included articles, and the present study did not provide a numerical understanding of the relationship between disordered gambling and family difficulties. However, this study was nevertheless able to organize the problems faced by family members in several dimensions. It is important to quantify the strength of these relationships through meta-analyses and other methods in the future.
Second, the included articles used a number of different definitions of gambling disorder. DSM criteria should be used to measure gambling disorder accurately, but unfortunately, researchers often use other measures. Most of the identified articles in this review did use a validated gambling measure and many used DSM criteria to identify gambling disorders. Even when DSM criteria were used, changes in DSM definitions and terminology over time can make it difficult to compare studies directly.
Third, and finally, since most of the studies included in this review comprised cross-sectional design research, we could not assume the causality. There remains a need for longitudinal studies, through which it should prove possible to clarify the causal relationships between each of the variables.
This review suggests how assessing, understanding, and addressing the difficulties of family or partner can lead to the recovery of the gambler as well as the family or significant other. By these approaches, it is possible to reduce ongoing family difficulties (violence, abuse, neglect, and family members’ mental or physical problems) and affect the development of future disordered gambling among children.
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Submitted December 18, 2020; accepted August 2, 2021. This article was peer reviewed. All URLs were available at the time of submission.
For correspondence: Tomonari Irie, Ph.D., School of Education and Culture, Hokusho University, 23 Bunkyodai, Ebetsu, Hokkaido 069-8511, Japan. E-mail: email@example.com
Competing interests: None reported (all authors).
Ethics approval: Not required.
Acknowledgements: Tomonari Irie used a grant from the Council for Addiction Behavior Studies.